Anesth Analg Research Articles

Careful Considerations for Midcrisis Consent to and Refusal of Blood Products

(Anesth Analg. 2024;138(1):85–88) Obstetric hemorrhage is difficult in any circumstance but is especially so in cases when a patient has previously stated that they refuse blood products; this is the case for many patients who identify as Jehovah’s Witnesses (JW). A recent article examined the ethical and legal implications of revisiting previous decisions about blood transfusions midcrisis, arguing that in some cases informed consent or refusal can take place while respecting religious views, as refusal before a crisis may not accurately represent their feelings while experiencing one. This article discusses concerns with the previous argument of Holland and colleagues, mainly the 2 points on which the argument stands: first, that there is literature suggesting that individuals change their minds when faced with crisis; and second, that midcrisis discussions about decisions honor patient autonomy.

Ondansetron for the Prevention of Pruritus in Women Undergoing Cesarean Delivery With Intrathecal Opioid: A Systematic Review and Meta-Analysis

(Anesth Analg. 2024;138(1):70–84) Intrathecal opioids are effective for postoperative analgesia following CD, but they also have unpleasant side effects including shivering, nausea, vomiting, respiratory depression, and pruritus. The mechanisms of intrathecal opioid-induced pruritus are largely unknown. It is unknown if ondansetron has an antipruritic effect when administered with neuraxial analgesia. This study is an up-to-date systematic review that addressed the effectiveness of ondansetron for the prevention of pruritus that is associated with intrathecal opioids in women having CD.

Ethical and Medicolegal Issues: When Obstetric Patients Who Refuse Blood Products Change Their Minds

(Anesth Analg. 2024;138(1):89–95) Patients with postpartum hemorrhage (PPH) often need blood transfusions, but there are groups of individuals who are morally or religiously against receiving transfused blood products. The most prominent religious group to refuse transfusions are Jehovah’s witnesses (JW); some may accept minor blood components such as albumin or cell salvage, but many refuse at least major blood components. The preferences and beliefs of these patients must be considered, along with ethical and legal implications surrounding the medical decisions during PPH. This article examines the implications, ethically and legally, of patients who are awake and able to participate in conversations about blood transfusions and change their minds about wanting to proceed, arguing that it is ethically necessary in specific circumstances for a physician to reassess a patient’s wishes mid-crisis and follow through with those decisions.

Ethical Principles Do Not Support Mandatory Preanesthesia Pregnancy Screening Tests: A Narrative Review

(Anesth Analg. October 6, 2023. doi: 10.1213/ANE.0000000000006669. Online ahead of print) The process of informed consent upholds the principle of patient autonomy, rooted in US constitutional principles of privacy and noninterference. It has been legally required in the United States since 1914, ensuring that individuals have the right to determine what happens to their bodies, as Schloendorff v. New York Society Hospital ruled. The recent US Supreme Court decision on abortion has raised concerns about maternal-fetal conflicts and the rights of pregnant patients to undergo elective anesthesia and surgery. Ethical and legal requirements for informed consent in medical testing vary, with challenges in addressing routine laboratory testing. Not all medical tests carry the same ethical implications, but they should all consider beneficence, nonmaleficence, and patient autonomy. Focusing on the need for preanesthesia pregnancy testing remains a concern in anesthesia and surgery practices. The primary premise is preventing harm to the fetus, but this must be supported by medical evidence and adhere to ethical standards. No study conclusively demonstrates that anesthetic agents significantly increase rates of early human fetal loss or malformations. There is no evidence that anesthetic drugs are generally teratogenic or pose a significant risk of harm to the fetus. While such risks are small, they cannot be guaranteed to be absent.

Undergraduate Anesthesia Skills for a Global Surgery Agenda: Students’ Self-Reported Competence

(Anesth Analg. 2023. doi: 10.1213/ANE.0000000000006375) To address the lack of clear guidelines for undergraduate anesthesia training, this study assessed the self-perceived competence of medical students in South Africa. Maternal mortality is a concern, with a significant portion of deaths attributed to anesthesia. The country faces a shortage of specialist anesthesiologists, putting the responsibility on nonspecialist medical officers, including newly qualified community service officers. The study investigates the readiness of medical students to provide anesthesia services, with varying exposure to training during internships. The findings aim to support South Africa’s health needs and may guide the goals of global surgery in other developing nations.

Migrant-Native Disparities in Obstetric Neuraxial Analgesia Use: The Role of Host-Country Language Proficiency

(Anesth Analg. 2023;137(4):870–881) Neuraxial analgesia (NA) is highly effective for labor pain relief, but its use varies among countries and is influenced by factors like ethnicity and region of origin. This study investigated how language proficiency affected NA utilization and satisfaction with labor pain management in migrant women compared to native women. Data came from the baMBINO study in Portuguese public hospitals, including migrant and native women. The study involved interviews conducted in various languages and excluded certain cases, resulting in a sample of 3697 women with singleton vaginal deliveries. This research aimed to explore the impact of language barriers on disparities in labor pain management.

Labor Analgesia Initiation With Dural Puncture Epidural Versus Conventional Epidural Techniques: A Randomized Biased-Coin Sequential Allocation Trial to Determine the Effective Dose for 90% of Patients of Bupivacaine

(Anesth Analg. 2023. doi: 10.1213/ANE.0000000000006691) Neuraxial labor analgesia includes the conventional epidural (EPL) technique as well as the combined spinal epidural and dural puncture epidural (DPE) techniques. Some advantages to the DPE technique have been discovered through research in comparison to the EPL technique. A study was conducted using a biased-coin up-down allocation method to determine the effective dose of bupivacaine needed to achieve initial analgesia in 90% of women in labor (ED90) using the DPE and EPL techniques. It was hypothesized that a lower bupivacaine dose would be needed with the DPE versus the EPL.

External Validation of a Multivariable Prediction Model for Placenta Accreta Spectrum

(Anesth Analg. 137(3):537–547) Placenta accreta spectrum (PAS) encompasses various forms of abnormal placental attachment and uterine invasion. PAS is a leading cause of severe postpartum hemorrhage and often leads to an emergency hysterectomy. Managing PAS and its associated complications, such as preterm birth, maternal morbidity, and neonatal intensive care unit admissions, is best achieved in tertiary-level hospitals equipped with specialized multidisciplinary care. To ensure the highest quality of care, proactive planning is essential. This involves identifying risk factors associated with PAS, facilitating rapid transfers to appropriate delivery facilities, efficient resource allocation, and minimizing the occurrence of life-threatening postpartum hemorrhage and its associated complications.

Randomized Assessment of the Optimal Time Interval Between Programmed Intermittent Epidural Boluses When Combined With the Dural Puncture Epidural Technique for Labor Analgesia

(Anesth Analg. 2023;136:532–539) Neuraxial labor analgesia has advanced to include the dural puncture epidural (DPE) and the programmed intermittent epidural bolus (PIEB) techniques. This study aimed to test the appropriate interval for effective analgesia when the DPE technique is followed by the PIEB technique. This study used fixed volumes of PIEB at 10 mL of ropivacaine 0.1% and 0.5 mg/mL of sufentanil.

Perioperative Care of Transgender and Gender-Diverse Patients: A Biopsychosocial Approach

(Anesth Analg. 2023;137:234–246) Health care disparities exist across populations, and one group that has come to the forefront in recent years is transgender and gender diverse (TGD) individuals. In general, TGD people have less access to health care and fewer individuals in this population seek care due to systemic inequity. These disparities lead to greater disease burden, a greater likelihood of missed care for a chronic health condition, and other worrisome outcomes. TGD individuals are increasingly seeking gender-affirming care (GAC), and this often involves anesthesiology professionals participation in gender-affirming surgery (GAS). This article describes a biopsychosocial approach to GAC that offers holistic care for TGD individuals from anesthetic professionals in particular.

Direct Comparison of Peak Bulk Flow Rate of Programmable Intermittent Epidural Bolus and Manual Epidural Bolus Using a Closed-End Multiorifice Catheter: An Experimental Study

(Anesth Analg. 2023;136:1198–1205) Labor analgesia is a popular and widespread technique for pain management during labor and delivery, with many facilities adopting an administration method of programmable intermittent epidural bolus (PIEB). Previous research has studied both advantages and disadvantages of PIEB, with a consensus that advantages outweigh disadvantages. Many institutions also give access to a manual epidural bolus for breakthrough pain and/or for underperforming epidural analgesia, and studies have shown that this combination tends to lead to greater patient satisfaction, greater sensory blockade and improved pain control. Though studies have analyzed the effects of these methods, knowledge is lacking for the comparison of flow rate between PIEB and manual bolus. Understanding any differences could be beneficial to current understanding of mechanisms of pain management during labor and delivery.

Nitrous Oxide: Primum Non Nocere

(Anesth Analg. 2023;136:613–615) The use of nitrous oxide (N2O) for labor analgesia is increasing across the world. N2O is being commonly used as an analgesic in Europe, Australia, New Zealand, Canada, the United Kingdom, Finland, and Sweden. Although its use is common in many areas N2O has not been proven effective and is harmful to the environment. The use of N2O for labor analgesia has increased in hundreds of health care facilities across the United States since 2012.

Maternal Cardiovascular Morbidity Events Following Preeclampsia: A Retrospective Cohort Study

(Anesth Analg. 2023;136:728–737) It has been shown that cardiovascular disease is related to preeclampsia. It has also been found that preeclampsia can increase the risk of heart failure, maternal mortality, and other cardiovascular conditions. This study aimed to show the relationship between cardiovascular diseases and preeclampsia in patients.

Ultrasound Assessment of Gastric Volume in Parturients After High-flow Nasal Oxygen Therapy

(Anesth Analg. 2023;137:176–181) High-flow nasal oxygen (HFNO) therapy is a preferred method of respiratory support for pregnant women but concerns have been raised for gastric complications because of the positive airway pressure. Pregnancy causes physiological changes that can increase the risk of oxygen insufflation into the stomach, as well as the risk of aspiration. Aspiration risk can be determined by ultrasound assessment of gastric volume and antral cross-sectional area (CSA). This study was designed to assess the safety of HFNO therapy by examining changes in antral CSA and gastric volume via ultrasonography before and after HFNO administration, with a hypothesis that 20 minutes of HFNO therapy would increase gastric volume by 50%.

General Anesthesia for Cesarean Delivery for Thrombocytopenia in Hypertensive Disorders of Pregnancy: Findings From the Obstetric Airway Management Registry

(Anesth Analg. 2023;136:992–998) In Africa, maternal morality following cesarean delivery is 50× more likely compared to morality rates in high-income countries, and spinal anesthesia (SA) is the preferred anesthetic method during cesarean delivery. For parturient patients with hypertensive disorders (ie, preeclampsia, eclampsia, or gestational hypertension), there is an increased risk for adverse outcomes, including spinal epidural hematoma following SA, so thrombocytopenia should be excluded before neuraxial blockade. An accurate platelet count is necessary before SA in emergent situations of fetal distress, which can be complicated when laboratory services are unavailable or off-site. The primary aim of this study was to determine which patients received general anesthesia (GA) when the presence of thrombocytopenia was known versus suspected. The secondary aim was perioperative platelet counts of patients with suspected thrombocytopenia to determine how often GA may have been avoided in favor of SA if platelet count was known.

Manually Controlled, Continuous Infusion of Phenylephrine or Norepinephrine for Maintenance of Blood Pressure and Cardiac Output During Spinal Anesthesia for Cesarean Delivery: A Double-Blinded Randomized Study

(Anesth Analg. 2023;136:540–550) Spinal anesthesia (SA) can induce maternal hypotension which may compromise uteroplacental and fetal perfusion. Current practices that counteract SA-induced vasodilation employ a phenylephrine or norepinephrine infusion through computer-controlled, fixed-rate, and manual delivery methods. The current study investigated the hemodynamic effects of continuous infusion of norepinephrine compared with phenylephrine in maintaining cardiac index (CI) during cesarean delivery (CD) under SA.

Sugammadex Use for Reversal in Nonobstetric Surgery During Pregnancy: A Reexamination of the Evidence

(Anesth Analg. 2023;136:1217–1219) Recent advances in technology have made life-threatening airway failures in obstetric anesthesia less and less frequent occurrences. Though these events are rare, they still occur and often result in death or very poor outcomes if not treated appropriately. Sugammadex has been shown to be a rapid and effective reversal technique for aminosteroid-induced paralysis in nonpregnant patients and has been associated with a 30% reduction in major postoperative pulmonary complications. There is a lack of evidence in the obstetric population, but it could potentially be assumed that results would be similar. This article reviews the history and effectiveness of Sugammadex and its potential for effectiveness in an obstetric population.

Outpatient Treatment With Gabapentin in Women With Severe Acute Pain after Cesarean Delivery is Ineffective: A Randomized, Double-blind, Placebo-controlled Trial

(Anesth Analg. 2023;136:1122–1132) Cesarean delivery (CD) is a common major surgery but frequently recoveries are uncomplicated. However, in some cases high pain levels during recovery last longer than expected, leading to continued postpartum opioid use. This circumstance is rare, but serious in those who experience it. One common method to reduce opioid use in this population is the prescription of gabapentin, though questions have been raised about its effectiveness. This study was designed to assess the effectiveness of gabapentin in stopping opioid use, reducing pain, and aiding in functional recovery for women who have continued pain after CD.

The Management of Pregnant Trauma Patients: A Narrative Review

(Anesth Analg. 2023;136:830–840) In the United States, trauma affects approximately 1 in 12 pregnancies and is the leading non-obstetric cause of maternal mortality. Although parturient patients should receive a comprehensive assessment in the event of trauma, studies suggest that fetal resuscitation is taking priority over maternal resuscitation.

The Management of Pregnant Trauma Patients: A Narrative Review

(Anesth Analg. 2023;136:830–840) Within the United States, trauma affects about 1 in 12 pregnancies and is the leading nonobstetric cause of maternal mortality. While in the event of trauma, parturient patients should receive a comprehensive assessment, studies suggest that fetal resuscitation is taking priority over maternal resuscitation.